A nurse is caring for a client who is in physical restraints. Which of the following actions by the client indicates the restraints can be discontinued?

The client apologizes for their prior behavior.

The client remains in control of their actions.

The client asks to be released from the restraints.

The client signs a behavioral contract.

Answer and Explanation

The Correct Answer is B

Choice A reason:
An apology from the client for their prior behavior, while it may be a positive step towards recovery, does not necessarily indicate that they have regained control over their actions or that they no longer pose a risk to themselves or others. The decision to discontinue restraints should be based on current behavior and risk assessment rather than past actions.

Choice B reason:
The primary goal of using physical restraints is to prevent harm to the patient or others when less restrictive interventions are not effective. If the client demonstrates control over their actions, it suggests that they are no longer at immediate risk of harm, and therefore, discontinuing restraints could be considered³⁴⁵. This aligns with guidelines that advocate for restraint use to be continually assessed and reduced or discontinued as soon as possible.

Choice C reason:
While a request to be released from restraints indicates a desire for freedom, it does not provide enough information about the client's current mental state or risk of harm. The healthcare team must assess whether the client's condition has improved to a point where restraints are no longer necessary.

Choice D reason:
Signing a behavioral contract is a positive step towards establishing trust and setting expectations for behavior. However, it is not an immediate indication that the client can safely have restraints removed. The effectiveness of such contracts depends on the individual's ability to understand and adhere to the agreed-upon behaviors.

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Correct Answer is C

Explanation

Choice A reason:
Electroconvulsive therapy (ECT) is not typically used to reduce the frequency of seizures. In fact, ECT induces controlled seizures as part of its therapeutic process. Therefore, a reduction in seizure frequency is not an indicator of ECT's effectiveness.

Choice B reason:
While ECT can be used to treat various psychiatric conditions, it is most commonly and effectively used for severe depression. It is not primarily indicated for reducing the frequency of panic attacks. Therefore, a reduction in panic attacks is not a primary measure of ECT's effectiveness.

Choice C reason:
Improvement in manifestations of depression is a key indicator of ECT's effectiveness. ECT is often used when other treatments for major depressive disorder have failed. Patients typically show significant improvement in mood, energy levels, and overall functioning after a series of ECT treatments.

Choice D reason:
Decreased fear of heights, or acrophobia, is not a condition typically treated with ECT. Phobias are usually addressed through therapies such as cognitive-behavioral therapy (CBT) rather than ECT. Therefore, a decrease in the fear of heights is not an indicator of ECT's effectiveness.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Choice A: Alcohol Withdrawal

Reason: Alcohol withdrawal occurs when a person with a history of heavy and prolonged alcohol use suddenly stops or significantly reduces their intake. Symptoms can range from mild (e.g., anxiety, tremors) to severe (e.g., seizures, delirium tremens). Given the client’s long history of alcohol use disorder and recent heavy drinking, they are at high risk for withdrawal symptoms.

Choice B: Delirium Tremens

Reason: Delirium tremens (DTs) is a severe form of alcohol withdrawal that includes symptoms such as confusion, hallucinations, and severe autonomic hyperactivity. It typically occurs 48-72 hours after the last drink. While the client is at risk for DTs, it is a specific subset of alcohol withdrawal and not the most immediate concern.

Choice C: Seizures

Reason: Seizures can occur as a complication of alcohol withdrawal, usually within 24-48 hours after the last drink. The client’s high blood alcohol level and history of heavy drinking increase this risk. However, seizures are a symptom of alcohol withdrawal rather than a separate condition.

Choice D: Hallucinations

Reason: Hallucinations can occur during alcohol withdrawal, particularly in severe cases like delirium tremens. They are a symptom rather than a standalone condition. The client’s history of heavy drinking and current intoxication make hallucinations a possibility, but they are part of the broader alcohol withdrawal syndrome.

Choice E: History of Alcohol Consumption

Reason: The client’s long history of alcohol use disorder and recent relapse are critical factors in assessing their risk for alcohol withdrawal. This history indicates a high likelihood of experiencing withdrawal symptoms if alcohol intake is suddenly reduced or stopped.

Choice F: Recent Bereavement

Reason: Recent bereavement, such as the loss of close family members, can be a significant emotional stressor and may contribute to relapse in individuals with a history of alcohol use disorder. However, bereavement itself is not a direct cause of alcohol withdrawal but rather a contributing factor to the client’s relapse.

Choice G: High Blood Alcohol Level

Reason: A high blood alcohol level (BAC) indicates recent heavy drinking, which can increase the risk of withdrawal symptoms once the alcohol level begins to drop. The client’s BAC of 310 mg/dL is significantly above the normal range (0 to 50 mg/dL), indicating severe intoxication.

Choice H: Unemployment

Reason: Unemployment can be a significant stressor and may contribute to the client’s relapse into heavy drinking. However, like bereavement, it is not a direct cause of alcohol withdrawal but rather a contributing factor to the client’s overall situation.

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A nurse is caring for a client who is in physical restraints. Which of the following actions by the client indicates the restraints can be discontinued?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has been receiving electroconvulsive therapy. Which of the following findings indicates the treatment is effective?

Correct Answer is C

Explanation

A nurse in a mental health facility is admitting a client. Exhibits Complete the following sentence by using the lists of options. The client is at risk for developing dropdown as evidenced by the client’s dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Choice F: Recent Bereavement

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A nurse is reviewing new prescriptions for a client who is experiencing acute manifestations of alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for this client?

A nurse is assessing a client who has post-traumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (Select all that apply)

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